Public Health and Primary CareBRIEF REPORT

Preventing quality improvement drift: evaluation of efforts to sustain the cost savings from implementing best practice guidelines to reduce unnecessary electrocardiograms (ECGs) during the preadmisison testing evaluation

Rabeel Ahmad, BA; Ellen Hauck, DO, PhD; Huaging Zhao, PhD, MS; and Joseph McComb, DO, MBA
Notes and Affiliations
Notes and Affiliations

Received: September 23, 2022

Accepted: July 11, 2023

Published: August 3, 2023

  • Rabeel Ahmad, BA, 

    Rowan-Virtua School of Osteopathic Medicine, Stratford, NJ, USA

  • Ellen Hauck, DO, PhD, 

    Professor and Vice Chair for Research, Department of Anesthesiology, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA

  • Huaging Zhao, PhD, MS, 

    Professor, Center for Biostatistics and Epidemiology, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA

  • Joseph McComb, DO, MBA, 

    Department of Anesthesiology, Lewis Katz School of Medicine at Temple University, Medical Director of Preadmission Testing at Temple University Hospital, Philadelphia, PA, USA

J Osteopath Med; 123(11): 547-554

Context: Medical professionals commonly fail to follow best practice guidelines. Drift, or a return to previous tendencies, is abundant in healthcare even when guidelines are followed initially. This “drift” was found internally at Temple University Hospital with preoperative electrocardiograms (ECGs). Best-practice guidelines were instituted and followed as a first step, but sustaining performance improvement was the ultimate goal.

Objectives: The objectives are to improve and maintain adherence to published guidelines for preoperative ECG testing at Temple University Hospital in a physician-led, nurse practitioner (NP)–staffed preadmission testing (PAT) clinic.

Methods: To start this quality improvement (QI) project, a retrospective chart review was completed to determine the number of ECGs performed in PAT at Temple University Hospital in 2017. New guidelines for ordering preoperative ECGs were then implemented, and Plan-Do-Study-Act (PDSA) cycles were performed over 3 years. A repeat retrospective chart review was completed and looked at ECGs ordered from 2018 through 2020. The number of ECGs completed in PAT before and after implementation of the new guidelines was then compared. In addition, the complexity of our surgical patients was estimated by looking at the yearly average American Society of Anesthesiology Physical Health Status (American Society of Anesthesiology [ASA] status) values assigned. Finally, the cost of performing each ECG was calculated, and the cost savings to the hospital over 4 years was determined.

Results: The baseline ECG rate for PAT in 2017, 2018, 2019, and 2020 at Temple University Hospital was 54.0 , 20.7, 22.3, and 21.9 %, respectively, which was a statistically significant decrease in ECG performance rate in the years after implementation of the PDSA project. The ASA status average remained constant, demonstrating that while patients’ medical diagnoses remained on average the same, reinforced training had been effective in preventing a return to previous liberal ordering tendencies. Over the course of 4 years, the reduction in unnecessary ECGs led to an estimated direct cost savings of $213,000.

Conclusions: Self-adoption of best-practice guidelines among clinicians is often poor; however, the barriers to adoption can be overcome with education and individual feedback. Sustaining performance improvement gains is challenging, but possible, as shown by example in one urban, academic teaching hospital’s physician-led, NP–staffed outpatient clinic.

Read Full Article